“YOU REALLY ONLY NEED TO KNOW THREE THINGS about medicine,” Dr. Steve Lacey explained to the gathering of 207 first-year students at Southwestern Medical School in Dallas this past fall. “One is, Oxygen is good! The second is, The blood goes round and round! And the third is, You have to make pee!”
The students got a big laugh out of Lacey’s lighthearted riff during the opening lecture of first-year biochemistry. But they were much too bright to have missed the more sobering irony beneath the humor. Medical knowledge has burgeoned to such a degree that it is all but impossible for aspiring doctors to master it. The knowledge glut would seem to demand even more of the specialization that has been the trend in medicine for the past quarter of a century. But the marketplace is demanding exactly the opposite—more primary-care physicians. Today’s generalists have to know everything about medicine, from Lacey’s three basic rules to the latest scientific developments, and they have to know how to run a cost-efficient clinical practice as well.
“Your medical education will not be completed in four years,” Lacey told them later in the lecture. “The nature of education has changed for you in a very dramatic way. In the past the teachers taught, you went to class, you did what they said, you got a grade. Well, I’ve got a news flash for you: I don’t care about your grades. The real test is coming five years from now, when you’re in the sack at two o’clock in the morning, and a nurse calls you about a problem with a patient. Do you know enough to take care of him?”
Not so long ago, deciding to be a doctor involved only certainties: Years of hard study would be rewarded with high income and equally high prestige. But the continuing explosion of biomedical knowledge guarantees that much of what today’s students are learning will be outdated by the time they graduate, necessitating rigorous and constant reeducation for the rest of their careers. Meanwhile, the vagaries of the marketplace dictate that there is no longer the certitude of big money at the end of the gauntlet. And for the first time in the history of the profession, there is a growing mistrust of doctors. “I can think of lots of other things I could do to make money,” observes first-year student Leslie Chin of Dallas, a 22-year-old second-generation Chinese American who was a National Merit Scholar and an honor graduate of UT-Austin. “But I can’t be concerned about making money. And I can’t be concerned about making A’s either. I just have to focus on remembering what’s going to make me a good doctor.”
For Southwestern, an institution that in fifty years has gone from educating students in army barracks to a $400 million medical center with three Nobel prizes to its name, the task of providing her with that knowledge may be its most daunting challenge yet. At Southwestern and other leading medical schools, the dueling forces of expanding knowledge and restrictions on the use of that knowledge imposed by the managed-care revolution have compelled reflection and innovation for the first time in decades. Curriculum is being rethought, training refashioned. Students are being educated by doctors who have scant experience with the realities of the modern medical marketplace. In many ways the job of having to learn too much, too fast is one that the students will have to do on their own.
“There was a time, I suppose,” says Southwestern’s dean, Dr. William Neaves, “when all that a doctor needed to know was uttered at one time or another during his medical education. No more. My ideal finished student today would be one who is grounded in all the basics we can offer in four years, but also has learned how to manage time and information and how to keep on learning.” Add to this the growing economic pressure on physicians—their two main sources of income, insurance companies and government, are cutting back—and the decision to become a doctor becomes an adventurous, if not risky, career choice.
IN A LARGE, DANK ROOM MARKED “ GROSS ANATOMY”—a double meaning that is all too apt—dozens of partially mutilated cadavers lie on stainless steel gurneys. Each grayish corpse is attended by four or five impossibly young first-year medical students, who today are taking a hands-on look